Individual benefit in heart sparing during DIBH-supported left breast radiotherapy.

Introduction: Deep-inspirational breath hold (DIBH) is an option for heart protection in breast radiotherapy; we intended to study its individual benefit. Materials and Methods: 3DCRT treatment planning was performed in a cohort of 103 patients receiving radiotherapy of the whole breast (WBI)/chest wall (CWI) ± nodal regions (NI) both under DIBH and free breathing (FB) in the supine position, and in the WBI only cases prone (n = 45) position, too. A series of patient-related and heart dosimetry parameters were analyzed. Results: The DIBH technique provided dramatic reduction of all heart dosimetry parameters the individual benefit, however, varied. In the whole population the best predictor of benefit was the ratio of ipsilateral lung volume (ILV)FB and ILVDIBH. In the WBI cohort 9-11 patients and 5-8 patients received less dose to selected heart structures with the DIBH and prone positioning, respectively; based on meeting various dose constraints DIBH was the only solution in 6-13 cases, and prone positioning in 5-6 cases. In addition to other excellent predictors, a small ILVFB or ILVDIBH with outstanding predicting performance (AUC ≥ 0.90) suggested prone positioning. Detailed analysis consistently indicated the outstanding performance of ILVFB and ILVDIBH in predicting the benefit of one over the other technique in lowering the mean heart dose (MHD), left anterior descending coronary artery (LAD) mean dose and left ventricle(LV)-V5Gy. The preference of prone positioning was further confirmed by anatomical parameters measured on a single CT scan at the middle of the heart. Performing spirometry in a cohort of 12 patients, vital capacity showed the strongest correlation with ILVFB and ILVDIBH hence this test could be evaluated as a clinical tool for patient selection. Discussion: Individual lung volume measures estimated by spirometry and anatomical data examined prior to acquiring planning CT may support the preference of DIBH or prone radiotherapy for optimal heart protection.

Impact of information technology supported serious leisure gardening on the wellbeing of older adults: The Turntable project.

OBJECTIVE: The study presented in this paper aimed to assess the effect of an Information Technology enabled community gardening program for older adults, developed by an international consortium. METHODS: We have executed a quantitative, pre- and post-test field trial with older adult volunteers to test the proposed programme in two European countries, Italy and Belgium (n=98). We used standardized and ad hoc questionnaires to measure changes in the volunteers' mental and psychological state during the trial. The statistical data analysis sought for differences in the pre- and post-test values of the key scores related to the perceived quality of life and benefits of gardening via paired-samples t-tests, and also tried to identify the important factors of significant changes via logistic regression. RESULTS: We found significant improvements in the perceived benefits of gardening and also in the scores computed from the WHO Quality of Life instruments, especially in the social sub-domains. The improvements were associated with the country, age, marital state and education of the volunteers. Higher age or being widow, divorced or single increased the odds of a significant improvement in the scores in more than one sub-domains. CONCLUSION: Though the two trial settings were different in some aspects, the observed significant improvements generally confirmed the positive effects of gardening concerning the perceived quality of life and benefits of gardening.

Chronic postoperative pain after non-intubated uniportal VATS lobectomy.

Introduction: Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy. Methods: Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery. Results: Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) (p = 0.868), at 6 months (9.4 vs. 12.4%) (p = 0.785), and at 12 months (3.3 vs. 5.9%) (p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant (p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain (p = 0.03), while cardiac disease (p = 0.6), perioperative morbidity (p = 0.228), prolonged air leak (p = 0.057), and repeat drainage (p = 0.626) were not. Conclusion: Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain.

Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis.

INTRODUCTION: The aim of our prospective study was to confirm validity and diagnostic accuracy of the modified Alvarado score, which was developed at the Department of Surgery, University of Szeged, on patients presenting with symptoms suggestive of acute appendicitis (right lower quadrant complaints) at the A&E department. PATIENT POPULATION, METHODS: 138 patients were included in our study between 01.01.2019 and 01.01.2020. For patients attending A&E, the first medic calculated and recorded the modified Alvarado score before surgical consultation. The consulting surgeon decided on further treatment without knowing the score. Validation of the score was based on the pathology report of the removed appendix (whether the operation was warranted, and if the score also supported indication for surgery), if there was readmission or surgery due to worsening symptoms after discharge from A&E. We also examined if there was any connection between the value of the Alvarado score and the severity of inflammation. Our aim was to prove that using modified Alvarado score at the A&E Units helps to reduce patient's waiting time and avoid unnecessary surgical consultations. Furthermore our study included measuring the diagnostic accuracy of the ultrasound examination (specificity, sensitivity). RESULTS: Based on the results, patients presenting at A&E had a mean modified Alvarado score of 6.5. Comparing the score to histological results showed that the specificity of the modified Alvarado score was 100%, and its sensitivity was 80.7%. Based on Spearman's rank correlation (0.796) and ROC analysis (AUC 0.968), the modified Alvarado score has an excellent predictive value in diagnosing acute appendicitis. When comparing the patients' waiting times with the use of modified Alvarado score and without it we found that there was a significant difference in group also in group under 4 points and in group over 7 points when using modified Alvarado score, so the diagnostic and therapeutic algorithm should be much quicker with the help of the score. We found a correlation between the severity of inflammation based on the Fisher's exact test. Rank correlation of the same question also showed a significant connection. All patients had an US examination during their diagnostic course, its sensitivity was 82.6%, specificity was 87%. Based on this, we can conclude that the predictive value of the imaging method is good. CONCLUSIONS: We can conclude according to our results that the predictive value of the modified score is excellent, and it can be safely applied by non-surgeons in urgent care in the differential diagnosis of acute appendicitis. The new score incorporates the results of an easily obtainable, ionising radiation free imaging method, the ultrasound, which was not included in previous scores. With the help of the new score, the number of unnecessary surgical referrals and waiting times for patients are reduced, excess examinations will become avoidable.

Mitochondrial Dysfunction in Trauma-Related Coagulopathy: Is There Causality? Study Protocol for a Prospective Observational Study.

Hemorrhage control often poses a great challenge for clinicians due to trauma-induced coagulopathy (TIC). The pathogenesis of TIC is not completely revealed; however, growing evidence attributes a central role to altered platelet biology. The activation of thrombocytes and subsequent clot formation are highly energetic processes being tied to mitochondrial activity, and the inhibition of the electron transport chain (ETC) impedes on thrombogenesis, suggesting the potential role of mitochondria in TIC. Our present study protocol provides a guide to quantitatively characterize the derangements of mitochondrial functions in TIC. One hundred eleven severely injured (injury severity score ≥16), bleeding trauma patients with an age of 18 or greater will be included in this prospective observational study. Patients receiving oral antiplatelet agents including cyclooxygenase-1 or adenosine diphosphate receptor inhibitors (aspirin, clopidogrel, prasugrel, and ticagrelor) will be excluded from the final analysis. Hemorrhage will be confirmed and assessed with computer tomography. Conventional laboratory markers of hemostasis such as prothrombin time and international normalized ratio will be measured and rotational thromboelastometry (ROTEM) will be performed directly upon patient arrival. Platelets will be isolated from venous blood samples and subjected to high-resolution fluororespirometry (Oxygraph-2k, Oroboros Instruments, Innsbruck, Austria) to evaluate the efficacy of mitochondrial respiration. Oxidative phosphorylation (OxPhos), coupling of the ETC, mitochondrial superoxide formation, mitochondrial membrane potential changes, and extramitochondrial Ca2+-movement will be recorded. The association between OxPhos capacity of platelet mitochondria and numerical parameters of ROTEM aggregometry will constitute our primary outcome. The relation between OxPhos capacity and results of viscoelastic assays and conventional markers of hemostasis will serve as secondary outcomes. The association of the OxPhos capacity of platelet mitochondria upon patient arrival to the need for massive blood transfusion and 24-h mortality will constitute our tertiary outcomes. Mitochondrial dysfunction and its importance in TIC are yet to be assessed for the deeper understanding of this common, life-threatening condition. Disclosure of mitochondria-mediated processes in thrombocytes may reveal new therapeutic targets in the management of hemorrhaging trauma patients, thereby leading to a reduction of potentially preventable mortality. The present protocol was registered to ClinicalTrials.gov on 12 August 2021, under the reference number NCT05004844.

Innovation in the treatment of non-melanoma skin cancer: daylight photodynamic therapy / Új eljárás a nem melanoma típusú bordaganatok kezelésében: "daylight" fotodinámiás terápia

Introduction: Photodynamic therapy is indicated for the treatment of superficial basal cell carcinoma, Bowen's disease and actinic keratosis. Reactive oxygen radicals are released from the metabolite of the topically applied photosensitizer that is excited by light, which selectively leads to the destruction of tumor cells. The procedure can be performed with an artificial light source or with the use of sunlight. The latter is called daylight photodynamic therapy, which is an effective and painless procedure. Objective: Our aim was to introduce daylight photodynamic therapy in actinic keratoses at our department and to optimize the treatment protocol for the local climatic conditions. Method: Three clinical trials were performed. The difference between the treatment protocols was between the incubation time of the photosensitizer on the skin and in the time patients spent under the sunlight. Results: When using the international treatment protocol, 73% of the actinic keratoses showed complete, while 27% partial remission. By reducing the proportion of time patients spent outdoor, complete remission was achieved in

Detection of exhaled methane levels for monitoring trauma-related haemorrhage following blunt trauma: study protocol for a prospective observational study.

INTRODUCTION: Early recognition and effective treatment of internal bleeding impose a cardinal challenge for trauma teams. The reduction of the superior mesenteric artery (SMA) blood flow is among the first compensatory responses to blood loss, thus being a promising candidate as a diagnostic tool for occult haemorrhage. Unfortunately, methods for monitoring the SMA flow have not been elaborated to date. Nevertheless, animal experiments suggest that exhaled methane (CH4) levels correspond to the SMA perfusion. We hypothesise that real-time detection of CH4 concentrations in the exhaled air is an applicable technique for the early recognition of haemorrhage in severely injured patients. We also hypothesise that exhaled CH4 levels reflect the volume of blood loss more accurately than conventional markers of blood loss and shock such as shock index, haemoglobin, base deficit, lactate, end-tidal carbon dioxide and sublingual microcirculatory indices. METHODS AND ANALYSIS: One hundred and eleven severely injured (Injury Severity Score ≥16), intubated, bleeding patients sustaining blunt trauma will be included in this prospective observational study. Blood loss will be detected with CT and estimated with CT-linked radiologic software. Exhaled CH4 concentrations will be monitored by attaching a near-infrared laser technique-based photoacoustic spectroscopy apparatus to the exhalation outlet of the ventilator on patient arrival. The primary outcome is the volume of blood loss. Need for massive transfusion and 24-hour mortality will constitute secondary outcomes. The relation of exhaled CH4 to study outcomes and its performance in predicting blood loss in comparison with conventional shock markers and microcirculatory indices will be tested. ETHICS AND DISSEMINATION: Our protocol (ID: 5400/2021-SZTE) has been registered on ClinicalTrials.gov (NCT04987411) and complies with the Declaration of Helsinki and has been approved by the medical ethics committee at the University of Szeged (Ref.nr.:121/2021-SZTE RKEB). It is in data collection phase, theresults will be shared with the scientific community through publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04987411; ClinicalTrials.gov, registered on 27 July 2021.

Early Return to Play After Anterior Cruciate Ligament Reconstruction: Is It Worth the Risk?

OBJECTIVE: To compare the outcomes of a 6-month-long accelerated rehabilitation with a 12-month-long rehabilitation. There is no consensus on the optimal duration of rehabilitation after anterior cruciate ligament reconstruction (ACLR). Trends in the past decades have shifted towards accelerated programs, often resulting in a return to play (RTP) at 4-6 months, postoperatively. However, longer rehabilitation cycles have recently experienced renaissance due to a greater understanding of graft remodeling. METHODS: Adult athletes who underwent ACLR between 2015 and 2018 by the same surgeon were included and followed-up prospectively for 24 months. Participants were allocated into two groups based on their RTP (6 months vs. 12 months) and compared with graft elongation, reoperation rate, and sports career (quit or continue) outcomes. RESULTS: Fifty-four patients underwent accelerated rehabilitation and 92 completed conventional rehabilitation. The accelerated rehabilitation was significantly associated with graft elongation-the accelerated rehabilitation group (n=9) and the conventional rehabilitation group (n=0), p<0.001-and need for reoperation-the accelerated rehabilitation group (n=5) and the conventional rehabilitation group (n=1), p=0.026. Although the relationship between rehabilitation time and quitting competitive sports did not reach significance at 0.05 level (p=0.063), it was significant when p<0.1, thereby showing a clear trend. CONCLUSION: Accelerated rehabilitation increased graft elongation risk. Knee laxity ≥3 mm measured at 6 months after ACLR should be accompanied by RTP time frame re-evaluation. Arthrometry checkups or routine magnetic resonance imaging shortly after RTP may be considered in cases of accelerated rehabilitation.

Drug consumption of suspected drug-influenced drivers in Hungary (2016-2018).

The hazard caused by driving under the influence of drugs (DUID) is determined by the time of consumption, dose and biological effects of a substance, as well as by synergistic drug interactions after multi-drug use. The aim of this work was to investigate the prevalence and pattern of psychoactive substance use of suspected DUID drivers and to present the advantages and disadvantages of the system currently used for determination of impairment in Hungary. Blood and urine samples, collected between 2016 and 2018, were taken from 2369 drivers with a positivity rate of 95% for at least one substance. Classical illicit drugs were detected in 76-87%, prescription medications in 9-15%, stimulant New Psychoactive Substances (sNPS) in 3-8%, and synthetic cannabinoids (SCs) in 20-22% of the positive samples. The most frequent substances according to substance groups were: classical illicit drugs: cannabis (n = 1240), amphetamine and methamphetamine (AM/MA) (n = 753), MDMA (n = 196), and cocaine (n = 180), medicines: alprazolam (n = 188) and clonazepam (n = 83), sNPS: N-ethyl-hexedrone (n = 115), SCs: 5 F-MDMB-PINACA (n = 267), AMB-FUBINACA (n = 92) and ADB-FUBINACA (n = 90). The median age of classical illicit drugs users was 29 years, prescription medicine users were 33 years old, sNPS users were 28 years, and SC users were 26 years old. Compared to the previous two years, we found pronounced changes in the ratio of sNPS (14% decrease) and SC users (10% increase), and in the pattern of NPS consumption. The ratio of multi-drug use varied between 38% and 50%. 69% of drivers tested positive were deemed impaired. Impairment was determined according to impairment limits (80-82%), multi-drug use (12-13%), and the result of medical investigation when a single active substance with no set impairment limit was detected in the blood (6-8%). The results of medical investigations may be uncertain due to the long time delay between arrest and clinical examination and to the structure of medical investigations created for determination of alcoholic impairment. In conclusion, a revision of the current medical investigation protocol is warranted to standardize clinical symptom scores that better correlate with driving impairment.

Bisphosphonate therapy associated with bilateral atypical femoral fracture and delayed union.

OBJECTIVES: The aim of this study was to identify the risk factors for developing atypical femoral fractures (AFF) and to examine the effect of bisphosphonate (BP) therapy on delayed bone union and bilateral fractures. PATIENTS AND METHODS: Between January 1st, 2012 and December 31st, 2020, a total of 74 AFF patients (8 males, 66 females; mean age: 75.4±7.2 years; range, 51 to 94 years) were recorded in two centers and retrospectively analyzed. A control fragility fracture group (n=143) was compared to the AFF group according to fracture characteristics, surgical fixation methods, comorbidities, and medications. The AFF patients were selected and subdivided according to their BP therapy: Group 1 (without BP) and Group 2 (with BP). Group 2 was further classified into Group 2a (<5 years of BP) and Group 2b (<5 years of BP). RESULTS: The multivariate logistic regression model showed that, BP drug use was the most significant risk factor in development of AFF (p<0.001, odds ratio= 10.749, 95% confidence interval: 3.886-29.733). The patients on BP showed longer bone union (Group 2 - 8.3±3.5 vs. Group 1 - 6.4±3.1 months, p=0.02; Group 2b - 9±3.8 vs. Group 2a - 7.3 ±3.9 months, p=0.09). Of all 19 cases of bilateral fractures, 14 were in Group 2 with BP use (p=0.11). Of 74 cases, 26 (35%) contralateral femoral X-rays were taken on admission and 24 (92%) showed AFF minor criteria signs. Of these 24 patients, 10 (42%) developed contralateral AFF. CONCLUSION: The most significant risk factor in development of AFF was BP drug use. Longer BP therapy (>5 years) showed longer delayed bone union, which was not significant. There was a relatively high risk of developing AFFs and bilateral fractures on BP therapy. In case of an AFF, a contralateral femoral X-ray must be always performed for signs of an impending fracture.

Early and late graftectomies in patients during a 5-year period - single unit data from the Department of Surgery, University of Szeged / Korai és késoi graftectomiák a Szegedi Sebészeti Klinikán - 5 év beteganyagában

Introduction. The rate of graft failure after kidney transplantation is 7­10% in the first year and 3­5% in subsequent years. The indication and exact timing of graftectomy is a matter of debate in some cases, particularly in the case of asymptomatic grafts that are no longer functioning. Methods. Data of patients who underwent kidney transplantation at the Transplantation Unit, Department of Surgery, Szeged, Hungary between January 1, 2015 and December 31, 2020 were analyzed. We reviewed the indications, timing and complications of graftectomies and compared early and late graftectomies. Results. 294 kidney transplants were performed during the study period. 37 patients (13%) of them underwent graftectomy. The most common indications were bleeding 11 (30%), arterial circulatory disorders 8 (22%), v. renal thrombosis 7 (19%), mixed active antibody and ongoing cellular rejection 7 (19%), and acute humoral rejection 4 (10%). Graftectomies were performed in 26 cases with inoperative and in 11 cases with functional graft. Comparing early and late graftectomies, 15 cases (40%) underwent early graftectomy within 30 days after transplantation and 22 cases (60%) underwent late graftectomy. Conclusions. The most common cause of graftectomies in the study period was acute bleeding, which is also due to disturbed homeostasis in chronic renal failure. In the case of the early ones, emergency surgery and in the vast majority of late graftectomies, elective surgery was performed.

Analysis of the factors influencing the delay times of patients with ST-elevation myocardial infarction / Az ST-elevációval járó myocardialis infarktuson átesett betegek késési idejét befolyásoló tényezok vizsgálata.

Összefoglaló. Bevezetés: Myocardialis infarktus esetén a panasz kezdetétol az ér megnyitásáig eltelt ido prognosztikus jelentoségu, a legtöbb szívizom megmentésére az elso órákban van lehetoség. A Nemzeti Szívinfarktus Regiszter alapján tudjuk, hogy hazánkban a teljes ischaemiás ido kedvezotlenül hosszú. Célkituzés: Az ST-elevációval járó myocardialis infarktusos betegek késési idejét befolyásoló tényezok azonosítása. Módszer: Prospektív klinikai vizsgálatot végeztünk, melynek során a Szegedi Tudományegyetemen a II. Belgyógyászati Klinika és Kardiológiai Központ Invazív Kardiológiai Részlegére érkezett STEMI-s betegek adatait gyujtöttük saját kérdoív alapján. Az adatgyujtés 2019. 01. 01. és 2019. 12. 20. között zajlott, 121 beteg adatait dolgoztuk fel. Eredmények: A medián bejelentési ido 83 perc, a medián prehospitális ido 252 perc, a medián teljes ischaemiás ido 304 perc volt. Az Országos Mentoszolgálat (OMSZ) értesítésekor minden késési ido szignifikánsan rövidebb volt, a Sürgosségi Betegellátó Osztály (SBO) vagy a háziorvos értesítéséhez viszonyítva (a teljes ischaemiás ido mediánja: OMSZ: 233 perc, SBO: 341 perc, háziorvos: 650 perc). A betegek lakhelye szignifikánsan befolyásolta a késési idoket és a választott betegutat: a bejelentési ido mediánja városban 60 perc, faluban 147 perc volt; az OMSZ-t értesítette a városi betegek 50%-a, a falusi betegek 25%-a. A közös segélyhívó szám ismerete szignifikánsan rövidítette a betegúthoz tartozó késési idot (a betegútkésés medián ideje, ha a segélyhívó számot ismerte: 178 perc, ha nem ismerte: 268 perc). Következtetés: A késési idok rendkívül hosszúak voltak. A legszorosabb összefüggést a késési idokkel a választott betegút mutatta. A városi emberek elobb jelezték panaszaikat, és gyakrabban választották a megfelelo betegutat, az OMSZ-t, így késési idejük is rövidebb volt. Eredményeink felhívják a figyelmet a társadalom edukációjának fontosságára, különös tekintettel a kis települések lakóira. Orv Hetil. 2022; 163(11): 438-445. INTRODUCTION: The time elapsing from myocardial infarction onset to revascularization is prognostic; the most myocardium can be saved in the first hours. According to the Hungarian Myocardial Infarction Registry, the total ischaemic time is long in Hungary. OBJECTIVE: We aimed to identify the factors influencing the delay times of patients with ST-elevation myocardial infarction (STEMI). METHOD: We performed a prospective clinical study and collected data from 121 patients presenting with STEMI at the Cardiology Center of the University of Szeged in 2019. We filled out a questionnaire by interviewing patients after primary coronary intervention. RESULTS: The medians of the patient delay, prehospital delay time and total ischaemic time were 83, 252 and 304 minutes, respectively. When the Ambulance Service (AS) was notified, every delay time was significantly shorter than those measured when the Emergency Department or the general practitioner was notified. The place of residence of the patients significantly influenced the delay times and the chosen pathway of healthcare: median patient delays were 60 and 147 minutes in cities and villages, respectively; AS was called first by 50% of urban patients vs. 25% of rural patients. Knowing the emergency number was associated with reduced delay times. CONCLUSION: Delay times were long. The chosen pathway of healthcare had the greatest impact on the delay times. Urban people reported their complaints sooner, were more likely to choose the best healthcare pathway (AS), thus their delay times were shorter. These suggest that it is important to educate the society, especially rural communities. Orv Hetil. 2022; 163(11): 438-445.

Kynurenic acid and kynurenine aminotransferase are potential biomarkers of early neurological improvement after thrombolytic therapy: A pilot study.

BACKGROUND: Biomarkers for predicting treatment response to thrombolysis in acute ischemic stroke are currently lacking. Both, animal models and clinical studies have provided evidence that the kynurenine (KYN) pathway is activated in ischemic stroke. OBJECTIVES: In our pilot study, we aimed to investigate whether KYN pathway enzymes and metabolites could serve as potential biomarkers for treatment response in the hyperacute phase of ischemic stroke. MATERIAL AND METHODS: We included 48 acute ischemic stroke patients who received thrombolysis. Blood samples were taken both before and 12 h after treatment. Concentrations of 11 KYN metabolites were determined using ultra-high-performance liquid chromatography-mass spectrometry. To assess the treatment response, we used early neurological improvement (ENI), calculated as the difference between the admission and discharge National Institutes of Health Stroke Scale (NIHSS) scores. We performed receiver operating characteristic (ROC) analysis for KYN pathway metabolites and enzymes that showed a correlation with ENI. RESULTS: In the samples taken before thrombolysis, significantly lower concentrations of kynurenic acid (KYNA) and kynurenine aminotransferase (KAT) activity were found in patients who had ENI (p = 0.01 and p = 0.002, respectively). According to the ROC analysis, the optimal cut-off value to predict ENI for KYNA was 37.80 nM (sensitivity (SN) 69.2%, specificity (SP) 68.4%) and 0.0127 for KAT activity (SN 92.3%, SP 73.7%). CONCLUSIONS: Our research is the first clinical pilot study to analyze changes in the KYN pathway in ischemic stroke patients who received thrombolytic treatment. Based on our results, baseline KYNA concentration and KAT activity could serve as potential biomarkers to predict early treatment response to thrombolysis.

Comparison of the Previous and Current Trauma-Related Shock Classifications: A Retrospective Cohort Study from a Level I Trauma Center.

PURPOSE: The aim was to examine the predictive value of the hypovolemic shock classification currently accepted by the Advanced Trauma Life Support (ATLS) program over the previous one, which used only vital signs (VS) for patient allocation. The primary outcome was 30-day mortality; as secondary outcome, heart rate (HR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS) and base deficit (BD) data were compared and investigated in terms of mortality prediction. METHODS: Retrospective analysis at a level I trauma center between 2014 and 2019. Adult patients treated by trauma teams were allocated into severity classes (I-IV) based on the criteria of the current and previous ATLS classifications, respectively. The prognostic values for the classifications were determined with Fisher's exact test and χ2 test for independence, and compared with the 2-proportion Z test. The individual variables were analyzed with receiver-operating characteristic (ROC) analyses. RESULTS: A total of 156 patients met the inclusion criteria. Mortality was effectively predicted by both classifications, and there was no statistically significant difference between the predictive performances. According to ROC analyses, GCS, BD and SBP had significant prognostic values while HR change was ineffective in this regard. CONCLUSIONS: The currently used ATLS shock classification does not appear to be superior to the VS-based previous classification. GCS, BD and SBP are useful parameters to predict the prognosis. Changes in HR do not reflect the clinical course accurately; thus, further studies will be needed to determine the value of this parameter in trauma-associated hypovolemic-hemorrhagic shock conditions.

Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review.

BACKGROUND: In the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS). METHODS: We performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms. RESULTS: Based on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential. CONCLUSION: NITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.

Individually selected teletherapy technique for accelerated partial breast irradiation.

BACKGROUND: The aim of the study was to individualize accelerated partial breast irradiation based on optimal dose distribution, protect risk organ and predict most advantageous technique. MATERIALS AND METHODS: 138 breast cancer patients receiving postoperative APBI were enrolled. APBI plans were generated using 3D-conformal (3D-CRT), sliding window intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT). In the case of superficial tumours, additional plans were developed by adding electron beam. To planning target volume (PTV) 37.5 Gy/10 fractions, 1 fraction/day was prescribed. A novel plan quality index (PQI) served as the basis for comparisons. RESULTS: IMRT was the most advantageous technique regarding homogeneity. VMAT provided best conformity, 3D-CR T - the lowest lung and heart exposure. PQI was the best in 45 (32.61%) VMAT, 13 (9.42%) IMRT, 9 (6.52%) 3D-CRT plans. In 71 cases (51.45%) no difference was detected. In patients with large PTV, 3D-CRT was the most favourable. Additional electron beam improved PQI of 3D-CRT plans but had no meaningful effect on IMRT or VMAT. IMRT was superior to VMAT if the tumour was superficial (p < 0.001), situated in the medial (p = 0.032) or upper quadrant (p = 0.046). CONCLUSIONS: In half of all cases, individually selected teletherapy techniques provide superior results over others; relevance of a certain technique may be predicted by volume and PTV localization.

Connection between small vessel disease related stroke and the MTHFR C677T polymorphism in a Hungarian population.

INTRODUCTION: There are conflicting results in the literature regarding the connection between thrombophilias and ischaemic stroke. However, most of the clinical studies have not differentiated between various ischaemic stroke subtypes. Our aim was to investigate whether there is an association between the methylene tetrahydrofolate reductase (MTHFR) C677T polymorphism and ischaemic stroke due to small vessel disease (SVD) in patients ≤50 years of age. PATIENTS AND METHODS: We performed a retrospective search in the database used at our Health Centre. Our study population consisted of 100 ischaemic stroke patients. 65 patients had MTHFR C677T variants: 21 were homozygous (TT allele), 45 were heterozygous (CT). 35 stroke patients did not carry MTHFR C677T polymorphism (wild genotype, CC). Stroke subtypes were determined according to the TOAST classification. Pearson's chi-squared test of independence was used to evaluate differences between subgroups and multivariate logistic regression was also performed. RESULTS: More than half of our study population (52.00%) had lacunar strokes. The ratio of SVD in patients ≤50 years of age with TT homozygous variant was significantly higher compared to heterozygous and wild type subjects (p = 0.032 and p = 0.03 respectively). Multivariate logistic regression also showed, that apart from hypertension, only TT homozygosity was a predictive factor for SVD related stroke (p = 0.014, OR 1.619, 95% CI 1.390-18.338). CONCLUSION: Our results demonstrate that in a Hungarian population of ischaemic stroke patients ≤50 years of age, SVD is the most common stroke subtype. In addition, we found association of SVD stroke with hypertension and MTHFR 677TT homozygous polymorphism.

Conversion method to manage surgical difficulties in non-intubated uniportal video-assisted thoracic surgery for major lung resection: simple thoracotomy without intubation.

BACKGROUND: The major limitations of widespread use of non-intubated thoracic surgery (NITS) is the fear of managing complications. Here we present our practice of converting from uniportal video-assisted thoracic surgery (VATS) NITS to open NITS in cases of surgical complications. METHODS: The study period was from January 26, 2017, to November 30, 2018. Total intravenous anesthesia was provided with propofol guided by bispectral index, and the airway was maintained with a laryngeal mask with spontaneous breathing. Local anesthesia with 2% lidocaine at the skin incision, and intercostal and vagus nerve blockades were induced using 0.5% bupivacaine. For conversion with surgical indications, a thoracotomy was performed at the incision without additional local or general anesthetics. RESULTS: In 160 complete NITS procedures, there were 145 VATS NITS and 15 open NITS (9 conversions to open NITS and 6 intended NITS thoracotomies). In the 15 open NITS cases (2 pneumonectomies, 1 bilobectomy, 1 sleeve lobectomy, 7 lobectomies, 3 sublobar resections, 1 exploration), the mean operative time was 146.7 (105-225) and 110 (75-190) minutes in the converted and intended open NITS groups, respectively. There were no significant differences between systolic blood pressure (P=0.316; 95% CI, -10.469 to 3.742), sat O2% (P=0.27; 95% CI, -1.902 to 0.593), or propofol concentration in the effect site (P=0.053; 95% CI, -0.307 to 0.002) but significant differences in pulse (P=0.007; 95% CI, -10.001 to -2.72), diastolic blood pressure (P=0.013; 95% CI, -9.489 to -1.420) and in end-tidal CO2 (P=0.016; 95% CI, -7.484 to -0.952) before versus after thoracotomy, but there was no clinical relevance of the differences. CONCLUSIONS: For conversion with surgical indications during the VATS-NITS procedure, NITS thoracotomy can be performed safely at the site of the utility incision without the need for additional drugs, and the major lung resections can be performed through this approach.

Age-Related Absorption of the Human Lens in the Near-Ultraviolet Range.

The purpose of the present study was to determine the age dependence of the ultraviolet (UV) absorption of the different parts of the human crystalline lens. Cryostat sections of human cadaveric lenses (60 µm) were cut. The UV absorbance of nine samples, derived from different parts of the lens, was determined using a Shimadzu scanning spectrophotometer. The absorbance of the anterior and posterior lens capsules was measured separately. The absorption coefficients were calculated from the measured absorbance and values taken at 280 as well as at 360 nm were compared statistically. ANCOVA analysis of the values taken at 280 and at 360 nm wavelengths shows that correlation between the absorption coefficients and age can be found only in the case of the posterior layers. These results suggest a differential age-dependent increase of the UV absorption of the posterior layers compared to the anterior ones and can be related to the differential protein expression in the anterior and posterior parts. Posterior crystalline lens capsules have higher absorption coefficients than the anterior ones regardless of age.